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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food Truck/ Taco Truck N/A <br /> OWNER I OPERATOR <br /> Salvador Perez X CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Tacos y Eventos Maya <br /> SITE ADDRESS Will be operating in Zip Code <br /> Street Number different locations 95206 <br /> Stockton <br /> Direction Street Name City <br /> HOME or MAILING ADDRESS (If Different from Site street Carrie Street <br /> Number: <br /> Address) <br /> 1042 Street Name <br /> CITY:Stockton STATE : CA ZIP : 95206 <br /> PHONE#1 EIT. (209 )227- 9570 APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Salvador Perez CHECK If BILLING <br /> ADDRESS <br /> BUSINESS NAME: PHONE# EXT. <br /> Tacos y Eventos Maya (209) <br /> 227-9570 <br /> HOME or MAILING ADDRESS 1042 Carrie Street FAX# <br /> CITY : Stockton STATE:CA Zip : 95206 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Salvador Perez Perez DATE:05/05/2020 PROPERTY/BUSINESS OWNER <br /> OPERATOR / MANAGER © 6 OTHER AUTHORIZED AGENT Business Owner If APPLICANT is not the BILLING PARTY, proof of <br /> authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: f�w V4 <br /> j A ,� n <br /> QIZ65q1600 <br />